9. Endodontic Emmergencies

Transcript

ENDODONTIC EMERGENCIES CONTENTS  INTRODUCTION  DEFINITION  MANAGEMENT  PRE-TREATMENT EMERGENCIES o ACUTE REVERSIBLE PULPITIS o ACUTE IRREVERSIBLE PULPITIS o ACUTE APICAL PERIODONTITIS o PULP NECROSIS WITH PERIAPICAL ABSCESS o ACUTE PERIODONTAL ABSCESS o TRAUMATIC INJURIES  CRACKED TOOTH SYNDROME  CROWN FRACTURE  ROOT FRACTURE  AVULSION  MID-TREATMENT FLARE-UPS o APICAL PERIODONTITIS SECONDARY TO TREATMENT o PHOENIX ABSCESS o RECURRENT PERIAPICAL ABSCESS o CAUSES o MICROBIOLOGY o PREVENTION AND TREATMENT o HYPOCHLORITE ACCIDENT  POST-TREATMENT EMERGENCIES o CAUSES AND TREATMENT  REFERRED PAIN  ROLE OF DRUGS  CONCLUSION Page 1 ENDODONTIC EMERGENCIES INTRODUCTION One time when our hours of learning are put into true practical test is when we get a frantic call or an unscheduled visit from a patient in distress, and that is when we know we know we are facing an endodontic emergency. An endodontic emergency is defined as an “An unscheduled visit associated with pain or swelling ensuing from pulpoperiapical pathosis requiring immediate diagnosis and treatment.” The fact that is associated with words like unscheduled and immediate, imply the emergency of the situation. Pain is the most common factor that motivates the patient to seek dental treatment. Approximately 90% of patients requesting dental treatment for the relief of pain have pulpul periapical disease and thus are candidates for endodontic therapy.Hence the alleviation of dental pain is one of the prime objectives of dental profession. MANAGEMENT OF ENDODONTIC EMERGENCIES: The management of endodontic emergencies can be summarized into the 3 P’s “Prompt, precise and polite” Polite: the dentist’s reaction to the patient is important for both pain and patient management. The clinician should understand the patients needs, fears about the immediate problem and defenses for coping with the situation. building a rapport with the patient goes a long way not only in treating but also preventing endodontic emergencies like flare ups. Precise :”Heed to the needs of the patient” Page 2 ENDODONTIC EMERGENCIES The main focus of the clinician should be on the chief complaint of the patient that drove him to the clinic. After a review of subjective and objective symptoms and determining a diagnosis, treatment of the tooth should be initiated first. Prompt: an emergency often requires the dentist to be prompt in his action so as to relieve the suffering patient. This may also be of particular significance in severe traumatic cases where the time elapsed has a strong impact on the prognosis of the tooth. We shall divide our management into the following steps: • Proper attitude • Make an accurate diagnosis • Provide profound anesthesia • Render prompt and effective treatment 1. Proper attitude: A calm and confident professionalism should be displayed . a positive attitude to the patients problem can make the individual aware that an efficient and effective treatment will be done. 2. Make an accurate diagnosis: In the instance of dental emergency when a patient is suffering acute pain or swelling and needs immediate relief, the essential diagnosis should be rapid and accurate. The patient’s emotional status as well as physical condition such as limited mouth opening or associated injuries can further complicate diagnosis. The step-by step approach for proper initial diagnosis and identifying the culprit behind the pain include: • Attaining pertinent medical and dental histories to avoid important medical complications or allergic reactions or make modifications in the treatment. • Subjective examination: questions relating to history, location, severity, duration character, stimuli eliciting/ relieving pain should be asked. The spontaneity, Page 3 ENDODONTIC EMERGENCIES intensity and duration of pain should be enquired. An astute clinician can arrive at a tentative diagnosis by thorough subjective examination alone. • Objective examination: includes- : • Visual examination of face, oral and hard soft tissues. Dental examination should follow to note presence of defective restoration, discolored teeth, recurrent caries, fractures etc. • Perform vitality testing to note pulpal status. Thermal tests are more useful as they mimic the stimuli which elecit /relieve the pain. • Periradicular tests including palpation over apex and light digital pressure/ percussion should be done to identify periapical inflammation as the source of pain. • Periodontal examination to check for pockets should be done. Probing helps in differentiating endodontic from periodontal diseases. Radiographic examination: helps in detecting recurrent / inter proximal caries, possible pulpal exposures, resorptions, periapical pathosis etc. Remember radiographs are an aid to diagnosis. Learn to use them and not abuse them. A differential diagnosis should be done to consider or rule out even nonodontogenic sources of pain which mimic odontogenic pain quite closely. Periodontal prognosis: All the above should be done quickly but correctly. Once the offending tooth and the tissue i.e pulp/ periradicular has been identified it is critical to determine the prognosis of the tooth. If the tooth is periodontally very weak with excessive pockets/bone loss Restorability: if the restorability of the tooth is questionable, then extraction is the best choice. The patient himself may not want treatment at times. 3. Provide profound anesthesisa: Attaining profound anesthesia in rendering emergency treatment can be difficult even for an experienced clinician. This is because: • The presence of an acidic environment due to inflammatory prcesses , the anesthetic molecule is prevented from disassociating into ionic fom and cation is unable to penetrate through neural sheath. Page 4 ENDODONTIC EMERGENCIES • In the presence of swelling an dinfection , local infiltration is contraindicated due to the pain caused to the patient and chances of spread of infection. • Conduction/block anesthesia is generally made use of. However inflamed nerve fibres are morphologically and biochemically altered through out the length by neurochemicals like neuropeptides(GRP). Therefore nerve blocks at a site distant frm the inflamed tooth are rendered less effective. To avoid this problem, the clinician should • Select alternative and supplementary sites of injection e.g. intraligamentary, and a few drops of intrapulpul injection. When the pulp is exposed these are effective adjuncts. • Consideration should be given to the type and amount of anesthetic used. Hot tooth: • It is the tooth that is difficult to anesthetize • scientists have shown that there is a special class of sodium channels on C fibres known as tetrodotoxin resistant (TTXr) . • these are five times more resistant to anesthetic then TTX sensitive channels. • Additional anesthetic or supplemental injections are required to achieve profound anesthesia. • Importantly bupivacaine was found to be more potent than lignocaine in blocking TTX channels CLASSIFICATION: Endodontic emergencies can be classified according to the time when they occur as: I: Pre treatment emergencies II: During Rx emergencies/ inter appointment ‘flare ups’ III: After Root canal Rx / post-obturation emergencies Page 5 ENDODONTIC EMERGENCIES Pre treatment emergencies 1. Acute reversible pulpits 2. Acute irreversible pulpits • Without apical periodontitis • With apical periodontitis 3. Acute apical periodontis 4. Pulp necrosis with acute periapical abscess • Without swelling • With swelling : - localized - diffuse 5. Acute periodontal abscess 6. Traumatic Injuries • Cracked tooth syndrome • Fracture a. Crown  Enamel  Enamel and Dentin  Enamel and Dentin with pulp exposure b. Root  Horizontal  Vertical • Luxated teeth • Avulsed tooth Acute reversible pulpitis / hyperemia Page 6 ENDODONTIC EMERGENCIES Definition: It is a mild to moderate inflammatory condition of the pulp caused by noxious stimuli in which the pulp is capable of returning to the uniflammed state following removal of stimuli Cause: : Trauma from a blow /disturbed occlusion : Thermal shock: cavity preparation / polishing : Excessive dehydration : Galvanic shock : Chemical stimulus: food /cements : Caries : Systemic conditions: circulatory disturbances, sinusitis Diagnosis: is by patients’ symptoms and clinical tests.  Subjective symptoms: The patient reports of a pain which is sharp, lasts a few seconds and disappears on removal of stimulus such as cold, sweet or sour foods. It does not occur spontaneously. Although the paroxysms of pain are of short duration they may continue for months .  Dental examination may reveal caries, large restorations, fracture and deep wear facets ,recently placed restrations, exposed dentin  Pulp vitality tests: o Thermal tests: helps to locate the offending tooth. Cold test is preferable. Percussion, palpation and radiographs give normal status. o Electric pulp test may give a slightly early response  Radiographic examination are normal Treatment: removal of noxious stimuli normally suffices.  If a recent restoration ahs a high point, recontouring the high spot will relieve the pain.  If persistent painful episodes occur following cavity preparation , chemical cleansing of the cavity or leakage of the restoration , one should remove the restoration and place a sedative dressing sucha s zinc oxide eugenol. Page 7 ENDODONTIC EMERGENCIES  If symptoms donot subside then pulpul inflammation should be regarded irreversible and pulpectomy should be done. Acute irreversible pulpitis Definition: It is a persistent inflammatory condition of the pulp, symptomatic/ nonsymptomatic, caused by noxious stimuli Cause:  Bacterial involvement of pulp because of caries  Deterioration of reversible pulpitis  Chemical, mechanical, thermal insults With no apical periodontitis: Diagnosis: Subjective symptoms: Pain is more severe, sharp or shooting which lingers even after removal of stimulus. Pain may be spontaneous, intermittent or continuous and may increase on lying down or an bending over i.e change of position exacerbates pain. Pain may get referred as well to the temples or sinus when an upper posterior tooth is involved.In later stages the pain may become dull boring and gnawig. Pain is increased by heat and sometimes relieved by cold. Dental examination may reveal a deep cavity with or without pulp exposure/ a fractured restoration / tooth etc. Radiographs may not show anything that is not already known clinically. Of course, it will help to disclose interproximal caries / a pulp horn involvement / caries below a filling. Thermal stimulus: Page 8 ENDODONTIC EMERGENCIES In the early stages it may elicit pain that persists after removal of stimulus. In late stages , when pulp is exposed it may respond normally to thermal stimulus bu generally it reacts feebly to heat and cold. Electric pulp tester: In the early stages it gives an early response while once an exposure has occurred it will respond to more current and give a delayed response. Thus, it is essential to differentiate an acute reversible pulpitis from an acute irreversible pulpitis without apical periodontitis.. The difference between the tooth is generally quantitative . In reversible pulpiis the cause pain can generally be traceable wheras in irreversible it can come from any stimulus. The treatment varies for both ,the latter will require a more aggressive emergency Rx than the palliative Rx used for the hyperemic tooth. Treatment: Pulpectomy is the Rx of choice but according to some authors in case minimal time is available, then a pulpotomy can be performed on a multi- rooted teeth. The latter Rx is justified in acute cases as the radicular pulp is probably relatively normal Hence, the removal of tissue in the pulp chamber will eliminate the site of inflammation that precipitates the painful response. Procedure:  Administer LA and open the access cavity.  With a spoon excavator and a large round bur remove the coronal pulp.  Place a cotton pellet with formocresol in the pulp chamber for 1minute.  Discard this pellet and place a new pellet in the chamber  Close the access with ZOE  Check occlusion and make needed adjustment  Fix appointment for continuation of root canal therapy For single rooted teeth total pulpectomy is done whenever possible pulpectomy should be the Rx of choice Page 9 ENDODONTIC EMERGENCIES With apical periodontitis : it is one of the most difficult emergency to be treated Diagnosis: Besides pain, symptoms well include tooth tenderness on vertical percussion and radiographs will show a widening of the periodontal ligament space or a small periapical radiolucency Treatment: - Anesthesia is administered in a heavy dose but even this may not give sufficient relief. This “hot” tooth will require additional supplemental injections. The proper approach is to be sympathetic towards the patient and ask him to bear a few minutes of discomfort till LA can be administered directly into the pulp tissue. Once roof of pulp chamber is removed, LA is given intra- pulpaly - As the inflammation has progressed apically, a total pulpectomy is performed. Some authors believe that pulpectomy of only the largest canals i.e palatal of upper molars/distal of lower molars which may house more toxins can be done due to the time constraints. Although, same patients may get relief from this, the best option is always complete debridement of all canals along with profuse irrigation. Radiographs should be evaluated carefully to prevent missing out an extra canal. - A closed dressing would be given to prevent ingress of contaminants, which will further aggregate the situation. - Occlusal reduction should be done Acute apical periodontitis: Definition: It is a painful inflammation of the periodontium as a result of trauma / infection through root canal regardless of whether pulp is vital(reversible pulpitis)/non vital (irreversible pulpitis). Cause:  Vital o Trauma o High pts Page 10 ENDODONTIC EMERGENCIES o Wedging of foreign objects  Non-vital o Sequelae to pulpal disease o Iatrogenic over-instrumentation metal /overmedication/ root perforation Symptoms: Pain and tenderness. The tooth is tender to percussion or slight pressure . Diagnosis: Tenderness on vertical percussion will be positive,subjective symptoms, pain on palpation may/may not be there, R/G will show PDL space widening Treatment It is important to know if the tooth is vital or not Vital: Occlusal adjustments Non-vital: RCT Pulp necrosis with acute periapical abscess Definition: It is the localized collection of pus in the alveolar bone at the root apex of a tooth following pulp necrosis with extension of infection through the apical foramen into the periradicular tissues. Cause: - Progression of pulpitis to pulp necrosis and extension into periapical tissues - Exacerbation of a chronic periapical lesion - Endo-perio lesion wherein a PD abscess secondarily affects the pulp and periapical tissues. - Trauma leading to pulp necrosis and supplementary to abscess It can present itself in 3 forms - Without swelling - With localized swelling - With diffuse welling Page 11 ENDODONTIC EMERGENCIES Diagnosis: Is made from subjective history and clinical examination. • Symptoms may vary from mere tenderness of tooth relieved by continuous pressure on extruded tooth to severe local reaction, swelling and systemic toxicity. The swelling is oedematous and diffused to begin with but then localizes and becomes fluctuant. • Vitality tests elicit no response • Apical palpation and percussion will give positive tenderness response. • Tooth may be mobile and extruded. • R/G ranges from no periapical change when inflammation is rapid to periapical radiolucency . in the latter case the acute abscess develops from a chronic lesion wheras in former the abscess is acute before it had a chance to destroy sufficient PA tissues for radiographic visualization. Differential diagnosis: One should be able to differentiate an acute alveolar abscess (AAA) from an acute periodontal abscess (APA) and acute irreversible pulpitis (AIP) as the Rx differs for each. AAA APA AIP Vitality Non Vital Vital / NN Vital /NV Origin pulp PDL Pulp Bone loss X V X Pain Dull,ache Throbbing Sharp lingual R/G Apical lesion Lat. Lesion No PA change Percussion TVP THP X Palpation Apical tenderness X X Pocket X / X Mobility / / X Treatment: Page 12 ENDODONTIC EMERGENCIES a) In case of an acute periapical abscess with no swelling, pain may be quite severe and very tender due to pressure apically with nowhere to vent. Even though the pulp is necrosed, some amount of apical tissues may be vital but inflamed. Thus, anesthesia should be given, following which opening is initiated. Remember to stabilize the tooth with finger pressure to avoid painful movement of tooth. - A note about anesthesia: - Block should be administered - Infiltration is contraindicated because - Insinuation of a needle into an acutely infected/ swollen area will cause more pain and also lead to spread of infection by dissemination of virulent organisms. - As an acutely inflamed tissue has an acidic pH, anesthetics, which are effective is alkaline pH will not be effective. - Once canals are debrided and irrigated copiously, partial canal preparation is done and a close dressing given. - In case of acute PA abscess with localised swelling, pain may be absent as the pressure which had build up by accumulation of toxic products has got relieved as the bone has perforated and the exduate has been able to expand through the soft tissues. - Actually, this cannot be called as a true emergency as the patient may not have any subjective symptoms such as pain or any systemic toxicity. However, the patient may notice the swelling and request an emergency Rx or worse still, may attempt to incise the area himself or use local agents such as aspirin over the area leading to injury and burns. This can result in a serious condition. - The proper Rx is biphasic- the 1st phase is canal debridement and 2nd phase is establishment of drainage - Once pulp chamber is opened and purulent discharge is present, then confine instruments within the canal. Though Grossman recommends this in all situations, Walton and Wein say that that when no drainage is seen due to a narrow apical constriction, then the apical foramen should be penetrated with a Page 13 ENDODONTIC EMERGENCIES small file #10,15,20 or #25 (not more) to initiate drainage. Drainage accomplishes 2 things: o Release of pressure o Removal of potentially irritating purulence. - Gentle finger pressure on mucosa overlying the swelling plus positive aspiration of the pulp chamber will aid in the drainage. Irrigation: - Is done initially using saline / warm sterile water while inducing drainage. Sodium hypochlorite has a tendency to clump the exudate causing apical constriction plugging and halting of drainage. Once patency is maintained, NaOCl can be used for further canal preparation. - At times drainage via the tooth cannot be established due to presence of post and core and crown / sectioned silver point / calcified canal/ intercommunicating abscesses. In these situations drainage must be established via apical soft tissue and frequently apical bone by a process called trephination or artificial fistulation. These options should be considered as the last resort (even though it takes lesser times) because o Area of incision is unnecessarily damaged o Relief is short lived o These procedures should be performed only when swelling is sufficiently localized to permit adequate drainage following incision. Diffuse swelling can become localized and by fluctuant by doing hot mouth rinses. Procedure: - A stab is made with #11 scalpel just below the most dependent point of the swelling. Once a purulent exudate is obtained, the apical bone is probed with an explorer to locate the perforation and it is enlarged with a spoon excavator/ file to ensure proper venting. The incision is left open with a 20x20 strip of H/ tube/triangular shaped rubber dam placed under the flap attached to the un- Page 14 ENDODONTIC EMERGENCIES retracted edge of the flap via a suture. This ensures further drainage. Antibiotics are prescribed and patient recalled after 4-7 days. - If “artifistulation” fails to relieve the pressure; then “trephination” i.e cutting a hole in the bone is done. The flap is increased for better visualization of apical bone. Using a fissure bur, the periapical bone is removed till the root tip is uncovered. Again a rubber dam drain is placed & antibiotics prescribed. - At the end of the procedure, tooth is dissoccluded. b) A periapical abscess can be associated with a diffuse swelling - which spreads through adjacent soft tissues, dissecting the fascial planes and turning into a medical emergency. This can be potentially life threatening. A more aggressive approach is needed. The pulp chamber is opened, canals are debrided, I & D performed and if systemic toxicity is seen, then an oral surgeon is contacted. - In mild cases of acute alveolar abscess, the tooth may be sealed with a mild obtundant antiseptic medicament. The debate over leaving a tooth open in such situations still goes on. Grossman strongly believes and supports the method of leaving a tooth open for drainage to reduce the possibility of continued pain and swelling and thus eliminating the need for an surgical intervention. - On the other hand, some others believe that a close dressing is better once drainage has subsided as this would prevent introduction of any new type of micro-organisms / food particle into the already infected periapical tissues. But these same people also say that if the exudation does not halt then canals should be left open. Another school of thought says: “If you file, don’t close and if you close, don’t file”, meaning a tooth which has been opened, irrigated and minimally instrumented can be closed while teeth in which complete canal enlargement has been done should be left open. The reason given is that during canal enlargement mass contaminants within the canals are inoculated into the periapical areas and closing will not allow venting of these elements leading onto flare ups. Page 15 ENDODONTIC EMERGENCIES - Antibiotic Coverage: is an aid to drainage. If the patient is afebrile and sufficient drainage has occurred, then antibiotic coverage is not needed but if minimal drainage is seen and the patient has systems of systemic toxicity then antibiotics are a must. Culture tests of the exudate will also aid in selecting the right type of antibiotics if symptoms don’t subside. Acute periodontal abscess It is a disease of the periodontium associated with infection and pus formation in an existing infra-bony pocket. It can occur in a vital as well as a non-vital tooth. It is often confused with an acute alveolar abscess. Rx: Vital= curettage and drainage via sulcular crevice Non-vital= RCT + curettage Traumatic Injuries: Emergency endodontic Rx may be required as a result of a traumatic injury. These include: - Cracked tooth syndrome - Crown fracture - Root fracture - Avulsion The treatment of impact injury due to automobile accidents, household mishaps, assault etc. is further complicated by local edema, bleeding etc. Accurate evaluation of the exact pulpal status is difficult via routine diagnostic tests due to temporary parasthesia of the pulp nerves. It is wiser to assume that the pulp is vital as this enhances the prognosis for healing. If later evidence indicates pulpal necrosis, extirpation can be carried out. Cracked tooth syndrome: It is an incomplete fracture of a tooth with a vital pulp. Page 16 ENDODONTIC EMERGENCIES Symptoms: Include pain on chewing and especially on release of pressure. Varied patterns of referred pain may be present and sensitivity to thermal changes may also be present. Diagnosis: Is based on subjective symptoms and by reproduction of the stimulus - Rubber polishing disc / cotton rolls are used - Tooth slooth - Fibre- optic light - Methylene blue staining Urgent Rx: Reduction of occlusal contacts by selective grinding Stainless steel band may be cemented temporarily using ZOE Definite Rx: Full occlusal coverage to present further propagation of crack Crown Fracture: Without pulp exposure: Could be of enamel alone or could be an enamel and dentin fracture Small E fracture with a sharp jagged edge can be smoothened with discs / stones to prevent irritation to tongue /lips. Composite build-up can be done for a larger enamel fracture. In case of dentin exposure, ‘sandwich’ technique with GIC and composite can be done. Sometimes, celluloid crowns can be cemented using a sedative cement like ZOE/ IRM to aid is recuperation of the pulp. With pulp exposure Vital pulp: The presence/ absence of apical closure must be determined via R/G: If apex is closed then Rx modality is same as in for acute irreversible pulpitis i.e total pulpectomy in anteriors and pulpotomy or pulpectomy in posteriors is done. If apex is open, apulpotomy is done followed by apexification procedures. Once apical closure is seen, routine endodontic treatment is done. Necrotic pull : Pulpectomy is done for teeth with closed apices and apexification for teeth with open apices. Root Fractures: Page 17 ENDODONTIC EMERGENCIES Horizontal root fracture: is an emergency if the tooth is painful or it the incisal segment is mobile. A fracture above the level of the alveolar crest has excellent prognosis while fracture at the mid root, below / at level with the crest of the alveolar bone has a guarded to poor prognosis unless it is amenable to orthodontic extrusion. Apical 1/3 fracture also has excellent prognosis. Emergency Rx consists of stabilization by ligation with adjacent teeth. A displaced/ luxated tooth is repositioned correctly and ligated. R/G is taken to check the position. The splint is kept for a week and vitality checked monthly. Vertical fractures: has a hopeless prognosis. Usually the emergency Rx is extraction but occasionally a multi-rooted tooth can be hemi-sectioned, root fragment removed and pulpectomy performed on the retained segment. Tooth avulsion: Which usually occurs of an anterior tooth due to trauma is both a dental and an emotional problem. The situation gets more complicated as immediate Rx is needed to enhance the prognosis since longer the tooth is out of its socket, the less likely chance that it will remain healthy functional after replantation. Rx: At site: When the PT/ Companion calls from the site, ask them to do the following 1. Wash tooth gently in water 2. ask PT to rinse mouth 3. Replace tooth in socket with gentle finger pressure. If PT co-operates get teeth into occlusion. 4. Visit clinic immediately 5. If tooth cannot be replaced, carry tooth in a moist vehicle to maintain viability of the PDL eg: - Saliva (in mouth/ collected) - Milk - Hanks Balanced salt solution (HBSS) - Last resort is water : It can cause cell lysis as it is hypotonic The extra oral time should not exceed 30 minutes. In clinic: Page 18 ENDODONTIC EMERGENCIES - If tooth is in socket, then ligate & stabilize using a heavy gauge rectangular orthodontic were contoured around 2-3 adjacent teeth and bonded using adhesive cements/ composite - Dissocclude the replanted tooth - Take R/G to confirm position of tooth in the socket. - Examine for root / bone fracture and also check adjacent teeth - Prescribe antibiotics as the tooth may have been contaminated - 1 week after replantation, endodontic Rx can be initiated and canals prepared - To prevent ankylosis, remove the splint and place the patient on soft diet - 2 weeks after replantation, Ca(OH)2 is placed to inhibit / reduce external resorption. - Monthly recalls should be conducted. - Once R/G confirmation of PDL reformation is done, reopen the tooth and complete the obturation. EMERGENCY DURING RX / MID - RX FLARE UPS The American Association of Endodontics defines a flare up as “an acute exacerbation of peri- radicular pathosis after the initiation / continuation of root canal treatment. Types of flare-ups include: 1. Apical periodontitis secondary to Rx = It is upsetting to both patient and dentist when a tooth involved in root canal therapy becomes sensitive to percussion during the course of Rx especially is the tooth was asymptomatic earlier. Throbbing / pounding pain is experienced. Cause is overinstrumentation / over- medication. 2. Recrudescence / Phoenix abscess: = Is an acute exacerbation of a chronic lesion after the initiation of Rx The reason is still unknown but some say that facultative anaerobes multiplying slowly in the low oxygen environment of the periapical tissues suddenly receive air on access opening and react violently producing an acute reaction. Though this theory is still under Page 19 ENDODONTIC EMERGENCIES dispute, one thing is for sure that a sudden change in environment has definitely something to do with this recrudescence. As multiple stains are harbored in a lesion, access opening and instrumentation can lead to reduction of some organisms and probably an increase in a virulent strain leading to an acute reaction. 3. Recurrent periapical abscess: = refers to a tooth with an acute abscess relieved by emergency Rx after which the acute symptoms return. Even if the tooth is left open to drain, food debris / foreign objects like segments of tooth pick may block the drainage resulting in exudate collection again. Abscesses can recur more than once due to highly virulent microorganisms or poor host resistance. When 2 such exacerbation are seen, it is better to do a periapical surgery and antibiotic coverage. According to Walton flare ups can occur in any type of tooth i.e teeth which were : - Vital, with no swelling and complete debridement. - Necrotic, no swelling - Swelling The causes of flare ups are often multi- factorial. The contributing factors include: 1. Inadequate debridement = presence of residual pulp tissue in adequately instrumented canals or still undetected canals allow bacteria and their toxins to remain and act as continuous irritants. It is seen that teeth with necrotic pulps are more prone to flare-ups than vital teeth. 2. Debris extrusion = Pulp tissue fragments, necrotic tissue, micro–organisms, dentinal shavings, canal irrigants are extruded beyond the apical foramen leading to periapical inflammation and pain. Conventional hand instrumentation has been shown to extrude more debris while coronal- apical preparations have shown to extrude lesser and sonic instrumentation is the least. 3. Over instrumentation = Moderate to severe pain is reported if instruments go beyond the apical foramen. Gross over-instrumentation & perforation can cause acute apical periodontitis, profuse exudation & inflammatory pain. Page 20 ENDODONTIC EMERGENCIES 4. Re-Rx cases = show higher incidence of flare-ups. These cases have been associated with periapical pathosis with symptoms that increase the likelihood of flare ups 5. Presence of periapical lesions = The pulps of teeth that have large periapical radiolucences have more bacterial strains and are more infected. These bacteria may cause an acute problem if inoculated periapically. On the other hand, presence of a sinus tract may pose fewer problems because of the potential space available for pressure release. In teeth with intact PDL, the increased pressure that develops, has nowhere to vent leading to pain. 6. Host Factors = The intensity of pre-operative pain and the amount of patient apprehension are co-related to degree of post-operative pain. The patients dental phobias, lower pain threshold etc can complicate Rx and increase the incidence of flare ups. The Microbiology and immunology of flare-ups: Cohen describes 7 possible etiologic factors responsible for endodontic flare-ups. 1. Local adaptation Syndrome The introduction of a new irritant into flamed tissue excerbates a chronic problem. 2. Periapical pressure change: a) Excessive exudates will increase pressure on nerve endings causing pain b) Decrease in pressure causes aspiration of irritants and micro– organisms into periapical space-causing inflammatory response 3. Association between certain micro-organisms and clinical signs and symptoms 4. Chemical mediators such as prostaglandins, leukotrins, Hageman factor, complement cascade 5. Changes in cyclic nucleotides 6. Immunological response 7. Psychological factors Page 21 ENDODONTIC EMERGENCIES Prevention of flare-ups: 1. Accurate working length determination to prevent over instrumentation 2. Complete debridement is preferable to placement of medicaments 3. Lengthen time of exposure to irrigants, when opening tooth with periapical lesion 4. Close dressing should be given unless a until excessive exudation is present. 5. Always inform the patient of the possibility of a flare- up. This reduces fear and anxiety Treatment: Usually post-operative pain diminishes within 72 hrs. 1. Occlusal reduction 2. If operator knows that the apex has been violated in the first appointment itself, then place corticosteroid – antibiotic paste . 3. Ca(OH)2 therapy to reduce bacterial colonies and their toxic by- products. This is does by:  Hydrolyzing the lipid moiety of bacterial lipopolysaccharide, rendering it incapable of producing biologic effects such as toxicity, pyrogenicity macrophage complement activation.  Absorbing CO2, thus starving capnophillic bacteria in the root canal system.  Obliterating the root canal space to minimize ingress of tissue exudate which is a nutrient source of micro-organisms.  Protein denaturation, leading to soft tissue dissolution due to its alkalinity. This enhances action of hypochlorite & better debridement occurs.  Reducing substrate adhesive capacity of macro phages, thereby reducing inflammation .. 4. Incision and drainage for swelling in case apical blockage has occurred. 5. Periapical surgery may have to be done if procedural mishaps/ failing re-Rx prevent non-surgical means from being effective. 6. Antibiotics and analgesics may be needed. Hypochlorite accident Page 22 ENDODONTIC EMERGENCIES Refers to any event where NaOCl is expressed beyond the apex of a tooth and the patient immediately manifests some combination of the following: - Severe, extreme pain (ever after induction of anesthesia) - Swelling within minutes - Profuse, prolonged hemorrhage through tooth and interstitially Causes: - Forceful injection of irrigating solution - Wedging / binding of needle - Large apical foramen / apical resorption / immature apex Symptoms Apart from the initial symptoms most patients have several days of increasing - Oedema - Ecchymosis - Tissue necrosis - Possible parasthesia and secondary infection The ultimate outcome depends upon the volume, concentration and the practitioners timely response to the incident. Management: - Don’t panic understand that Hypochlorite accident has occurred - Administer regional block with a long acting anesthetic. An IM injects of sedative and analgesic will help too. If available, nitrous oxide sedation will help the patient cope with the rest of the emergency. - allow the bleeding to continue as it is the body’s response to dilute the toxic fluid. High volume evacuation will aid further drainage. - Home care instructions to the PT includes cold compresses for the 1st 6 hours to bring down the pain and swelling and then warm compresses to aid healing. - Antibiotic, analgesic and corticosteroid coverage should be considered. This type of an incident is totally avoidable by doing the following: • Bend the irrigating needle at the center to confine the tip to higher levels within the root canal. • Never let the needle bind to the walls. Page 23 ENDODONTIC EMERGENCIES • Oscillate the needle in and out while delivering the irrigant passively. POST ENDODONTIC EMERGENCIES These emergencies occur after the root canal system has been obturated. Patient may complain of pain or swelling. These occur due to: 1) Over- obturation with gutta-percha/ sealer extrusion 2) Poor obturation i.e. poor apical/ coronal seal 3) High points causing premature occlusal contacts 4) Obturating when tooth is tender / if wet canal 5) Single- sitting endodontics Rx includes - Reassuring the patient. - Re-Rx if obturation is inadequate or wherever possible. - If Re- Rx not possible or pain is persistent then periapical surgery should be considered. - Incision & drainage in case swelling is present and obturation looks adequate. - Occlusal reduction. - If all the above fail, then the last resort unfortunately, is extraction. REFERRED PAIN Accurate determination of the origin of the patients pain is the fist step of emergency endodontics Rx. Although the most frequent and common cause of dental pain is pulpo-periapical pathosis, one knows that pain can originate from sources in close proximity to the dental region and simulate pulpo-periapical disease. A patients oral and facial pain complaints may originate from: 1. Pulpal tissue 2. Periodontal tissues 3. Tissues from adjacent sites including sinus, eye,ear, nose, throat, cervical spine, brain, heart Page 24 ENDODONTIC EMERGENCIES 4. Neurological system eg: Trigeminal neuralgia 5. Psychological systems eg: mental stress, depression 6. Vascular walls eg: migrane, MI 7. Musculo-skeletal tissues eg. MPDS,TMJ arthrosis 8. Idiopathic Pain disorders that mimic odontolgia can be: 1) Typical pain disorders (in which pathogenesis is known) 2) Atypical pain disorders (with unknown etiopathogenesis) Quite a few conditions mimic odontalgia. An astute clinician should be able to diagnose accurately the origin of pain as being odontogenic or non odontogenic and not jump to conclusions and start treatment, as relief may not be achieved by routine endodontic Rx. THE ROLE OF DRUGS Recent research supports the idea that antibiotics are generally unnecessary. Careful cleaning and shaping, using crown-down technique and copious irrigation should result in a low flare up rate. Antibiotics are indicated for: - a diffuse swelling which drains inadequately - After any endodontic surgery - A fibrile patient showing signs of systemic toxicity - After replantation of avulsed teeth - For prophylactic coverage of a medically compromised patient The most effective antibiotics in endodontic emergencies is penicillin as it is bactericidal and prevents cell wall synthesis. If Pn is ineffective after 48-72 hrs, then a combination with Metronidazole should be prescribed. Page 25 ENDODONTIC EMERGENCIES Pn VK (500mg) 2-1-1-1 x 7 days. PTs with P n allergy should be given Clindamycin (150mg) 2-1-1-1 x 7 days. Erythromycin has been shown to be ineffective against anaerobes associated with endodontic infections. For combating pain, NSAIDs are the drug of choice. Aspirin, acitaminophen, diflunisol, ibuprofen are usually prescribed but one should keep in mind the sideeffects and the contraindications for each. For eg: Aspirin should not be given for a PT undergoing anticoagulant therapy or brufen should not gives to asthmatic PT’s or those with a H/O peptic ulcer. Though narcotic/opioid drugs like morphine/codein control pain better, they can easily be abused and can also cause toxic reactions if taken along with alcohol, antihistamines or barbiturates. Hence, they should be prescribed with discretion. Corticosteroids like oral dexamethasone or methylprednisolone may be prescribed to patients with severe pain caused due to inflammation and injury. Conclusion: Handling an emergency is not easy. If a sincere effort is made at proper diagnosis and effective Rx, you can “emerge” out of this “emergency” as a true hero. Making the right judgment, the right decision, at the right time and in the right manner will definitely guarantee you success and friend for life. REFERENCES • Ingle 6th edition • Endodontic practice: Grossman 11th edition • Life as an endodontic pathogen. Endodontic topic 2003 vol 6 • Aetiology of root canal treatment failure: why well-treated teeth can fail. IEJ 2001 • Control of Microorganisms In Vitro by endodontic Irrigants. Braz Dent J (2003) 14(3): 187-192 • Essentials of diagnostic microbiology - Lisa Anne Page 26 ENDODONTIC EMERGENCIES • Basic medical microbiology - Parti • Google.co.in Page 27